Relating to the processes for and the adjudication and payment of certain claims under the workers' compensation system.

89(R) HB 2369 - Introduced version - Bill Text

89R8805 KKR-D

By: Patterson

H.B. No. 2369

A BILL TO BE ENTITLED

AN ACT

relating to the processes for and the adjudication and payment of

certain claims under the workers' compensation system.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:

SECTION 1. Section 408.0042, Labor Code, is amended by

amending Subsections (a), (c), (d), (e), and (f) and adding

Subsection (a-1) to read as follows:

(a)
Subject to Subsection (a-1), the
[
The
] division shall

require an injured employee to submit to a single medical

examination to define the compensable injury on request by the

insurance carrier.

(a-1)

In this subsection, the terms "custodial officer,"

"detention officer," "emergency medical technician,"

"firefighter," and "peace officer" have the meanings assigned by

Section 607.051, Government Code.

On request by an injured

employee who is a custodial officer, a detention officer, an

emergency medical technician, a firefighter, or a peace officer,

the division shall authorize the performance of a medical

examination to define the compensable injury, regardless of whether

an examination under Subsection (a) was previously performed.

(c) After
a
[
the
] medical examination is performed
under

Subsection (a) or (a-1)
, the treating doctor shall submit to the

insurance carrier
and the division
a report that details all

injuries and diagnoses related to the compensable injury, on

receipt of which the insurance carrier shall:

(1) accept all injuries and diagnoses as related to

the compensable injury; or

(2) dispute the determination of specific injuries and

diagnoses.

(d) Any treatment for an injury or diagnosis that is not

accepted by the insurance carrier under Subsection (c) as

compensable at the time of the medical examination under Subsection

(a)
or (a-1)
must be preauthorized before treatment is rendered. If

the insurance carrier denies preauthorization because the

treatment is for an injury or diagnosis unrelated to the

compensable injury, the injured employee or affected health care

provider may file an extent of injury dispute.

(e) Any treatment for an injury or diagnosis that is

accepted by the insurance carrier under Subsection (c) as

compensable at the time of the medical examination under Subsection

(a)
or (a-1)
may not be reviewed for compensability, but may be

reviewed for medical necessity.

(f) The commissioner may adopt rules relating to

requirements for
:

(1)

a request for an examination under Subsection (a)

or (a-1); or

(2)
a report under this section, including

requirements regarding the contents of a report.

SECTION 2. Section 409.021, Labor Code, is amended by

adding Subsection (a-4) to read as follows:

(a-4)

In this subsection, the terms "custodial officer,"

"detention officer," "emergency medical technician,"

"firefighter," and "peace officer" have the meanings assigned by

Section 607.051, Government Code. Notwithstanding any other

provision of this title, an insurance carrier who does not contest

the extent of an injury on or before the 60th day after the date the

carrier receives the report described by Section 408.0042(c) waives

its right to contest the extent of injury specifically claimed by

the employee or reasonably reflected in the employee's medical

records available to the carrier for review during that time

period, if the employee is a custodial officer, a detention

officer, an emergency medical technician, a firefighter, or a peace

officer.

SECTION 3. Section 409.022, Labor Code, is amended by

adding Subsections (c-1) and (c-2) and amending Subsection (d) to

read as follows:

(c-1) For purposes of
[
(d) In
] this
section
[
subsection
],

the terms "custodial officer," "detention officer," "emergency

medical technician," "firefighter," and "peace officer" have the

meanings assigned by Section 607.051, Government Code.

(c-2)

In addition to the other requirements of this section,

an insurance carrier's notice of refusal to pay benefits under

Section 409.021 sent in response to a claim for compensation by an

injured employee who is a custodial officer, a detention officer,

an emergency medical technician, a firefighter, or a peace officer

must include a statement by the carrier that:

(1)

for purposes of Subsection (a), includes the

specific reasons why the carrier is disputing the compensability of

the injury or the extent of injury; and

(2)

describes the evidence that the carrier reviewed

in making the determination to dispute the issue under Subdivision

(1).

(d)
In addition to the other requirements of this section,

if an insurance carrier's notice of refusal to pay benefits under

Section 409.021 is sent in response to a claim for compensation

resulting from a custodial officer's, a detention officer's, an

emergency medical technician's, a firefighter's, or a peace

officer's disability or death for which a presumption is claimed to

be applicable under Subchapter B, Chapter 607, Government Code, the

notice must include a statement by the carrier that:

(1) explains why the carrier determined a presumption

under that subchapter does not apply to the claim for compensation;

and

(2) describes the evidence that the carrier reviewed

in making the determination described by Subdivision (1).

SECTION 4. Subchapter D, Chapter 410, Labor Code, is

amended by adding Section 410.170 to read as follows:

Sec.

410.170.

EFFECT OF DECISION: REIMBURSEMENT OF CERTAIN

MEDICAL EXPENSES.

(a)

In this section, the terms "custodial

officer," "detention officer," "emergency medical technician,"

"firefighter," and "peace officer" have the meanings assigned by

Section 607.051, Government Code.

(b)

Notwithstanding the amount of an award of benefits due

in a written decision by an administrative law judge under Section

410.168, an insurance carrier shall reimburse an injured employee

who is a custodial officer, a detention officer, an emergency

medical technician, a firefighter, or a peace officer for all

medical expenses incurred by the employee that are related to the

specific injury claimed by the employee if:

(1)

the carrier denied the employee's claim for

medical benefits;

(2)

the decision of the administrative law judge

includes a determination that the injury is compensable; and

(3)

the decision of the administrative law judge is

not appealed to the appeals panel and becomes final.

SECTION 5. Subchapter E, Chapter 410, Labor Code, is

amended by adding Section 410.2051 to read as follows:

Sec.

410.2051.

EFFECT OF DECISION: REIMBURSEMENT OF CERTAIN

MEDICAL EXPENSES.

(a)

In this section, the terms "custodial

officer," "detention officer," "emergency medical technician,"

"firefighter," and "peace officer" have the meanings assigned by

Section 607.051, Government Code.

(b)

An insurance carrier shall directly reimburse an

injured employee who is a custodial officer, a detention officer,

an emergency medical technician, a firefighter, or a peace officer

for all medical expenses incurred by the employee that are related

to the specific injury claimed by the employee if:

(1)

the carrier denied the employee's claim for

medical benefits; and

(2) either:

(A)

the administrative law judge's determination

that benefits are owed becomes final without an appeal; or

(B) the appeals panel:

(i)

affirms the administrative law judge's

determination that the benefits are owed; or

(ii)

reverses the administrative law

judge's determination that the benefits are not owed.

(c)

If the appeals panel affirms the administrative law

judge's determination that the benefits are owed, the insurance

carrier shall directly reimburse the employee for all medical

expenses incurred by the employee that are related to the specific

injury claimed by the employee, regardless of the amount of an award

of benefits due in the written decision by the administrative law

judge under Section 410.168.

(d)

The insurance carrier must reimburse the injured

employee under Subsection (b), regardless of whether the appeals

panel's decision is appealed for judicial review.

SECTION 6. The changes in law made by this Act apply only to

a claim for workers' compensation benefits based on a compensable

injury that occurs on or after the effective date of this Act. A

claim based on a compensable injury that occurs before that date is

governed by the law as it existed on the date the compensable injury

occurred, and the former law is continued in effect for that

purpose.

SECTION 7. This Act takes effect September 1, 2025.